SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM

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1 SAMPLE SUPPORTIVE HOUSING INTAKE/ASSESSMENT FORM (This form must be completed within 30 days of program entry) IDENTIFYING INFORMATION Date Information is Gathered: 1. Applicant Last Name: First Name: MI: 2. Address: 3. City: State: Zip: Zip of Last Address: 4. Phone where applicant can be reached: (ex. xxx-xxx-xxxx) 5. Social Security Number: 6. Date of Birth: 6a. Place of Birth: (ex. NNN-NN-NNNN) (mm/dd/yyyy) 7. Gender: a. Male b. Female c. Transgender 8. Race: a. White b. Black/African American c. Asian d. Multi-Racial (Please specify) 9. Ethnicity: a. Hispanic or Latino b. Non Hispanic or Non-Latino 10. What is applicant s primary language? Secondary language, if applicable? 11. Relationship Status: a. Single b. Married c. Widowed/Widower d. Married & Separated e. Divorced f. Significant Other g. Domestic Partner h. Other (Specify) 12. Are there any identified, past or current, domestic violence issues? Yes No Currently a. Please describe, with dates of incidents. 13. Is applicant a Veteran, (anyone who has been on active military duty) Yes No

2 FAMILY 14. Enter family members that may live with the applicant (If applicable, complete attached Children s Education Form) Name (Not Applicant) Relationship to Applicant Social Security Number Gender Date of Birth a. Identify any service needs of applicants immediate family members: b. Identify any family members who have been supportive: c. Identify any family members who have not been supportive: 15. Enter family members that do not live with the applicant : Family Providers Only If the parent/guardian of children, identify the number of children and dates of birth of children living in the home. For Children age 6 or older, name of school attending, any after-school or activities the children are attending. For children age 0-5, identify participation in Head Start/Early Head Start, or school readiness, program, Birth to Three day dare. For school aged children, information about school attendance/absenteeism. Name (Not Applicant) Relationship to Applicant Social Security Number Gender Date of Birth

3 15a. Child Welfare Involvement: For Parents of minor children, including non-custodial parents, history of child welfare involvement, including current case status: 15b. Identify the ability of the parent(s)/guardian(s) to meet the needs and ensure the safety of minor children. Identify parenting strengths and areas of support needed: SUPPORTIVE HOUSING REFERRAL 16. Date of Referral 17. Referring Person s Name: 18. Referring Person s Agency & Telephone Number: 19. Application Date: HOUSING HISTORY As part of questions 20 & 21, the attached Homelessness Verification Form needs to be completed. 20. Is this person at risk of homelessness? Yes No a. Please describe circumstances: 21. Length of homelessness this episode: a. Not homeless at present e. At least 1 year but less than 2 years b. Less than one month f. Two years but less than three c. At least 1 month but less than 6 months g. Three years or more d. At least 6 months but less than 1 year 22. Number of episodes in past five years: 23. Approximate number in lifetime: 24. Within the last four (4) years, how many nights, months, or years, if any, have you spent in a shelter (s)? a. Could you provide the names and dates of your shelter stay?:

4 25. Where have you slept for the last thirty (30) days? Check all that apply. Check all that apply. a. Non-housing (Street, park, car) b. Emergency Shelter, please name. c. Transitional Housing d. Psychiatric Facility e. Substance Abuse Treatment Facility f. Hospital g. Prison/Jail h. Domestic Violence Shelter i. Living with friends/family j. Rental Housing k. Own apartment or house l. Motel/hotel m. Foster Care n. Other (specify): 26. Is applicant receiving a housing subsidy? Yes No a. What type of housing subsidy is the applicant receiving? 27. Does/did applicant pay own rent? Yes No 28. Does/did applicant pay for own utilities? Yes No 29. Has applicant ever been evicted? Yes No 30. Reason for leaving last housing situation. a. Eviction due to unpaid rent b. Eviction for reason other than unpaid rent c. Conflict with friends or family d. Overcrowding e. Domestic violence f. Incarceration g. Hospitalization, including long term treatment h. Housing condemned i. Fire j. Other, please explain 31. Please list housing history for last five (5) years including: Location, approximate dates, lease holder or relationship to primary tenant, reason(s) for leaving. 31a. Please identify any contributing factors to housing instability:

5 PERSONAL HEALTH INFORMATION As part of questions 32 & 33, the attached Disability Verification Form needs to be completed. 32. Does applicant have a disability of a long duration? Yes No Don t Know Refused 33. Is applicant currently or have they ever been diagnosed with any of the following? a. Mental illness... Yes No Currently b. Alcohol abuse Yes No Currently c. Drug abuse.. Yes No Currently d. HIV/AIDS and related diseases... Yes No Currently e. Developmental disability Yes No Currently f. Physical disability... Yes No Currently 34. Does applicant have a history of any psychiatric conditions? Yes No Check all that apply. Homicidal ideas/attempts Assaultive behavior Delusions Severe depression Severe thought disorder Cognitive impairment Suicidal ideas Suicidal attempts Hallucinations Arson/fire setting Victim of Sexual abuse/assault Victim of Trauma Other (specify) Currently Experiences: History of: a. If applicable, please list hospitalizations for these conditions. 35. Does applicant receive psychiatric care? Yes No a. If yes, please list name, address and phone number of all psychiatric care providers. 36. Does applicant have a history of any substance abuse disorders? Yes No a. If yes, please list drug(s) of choice, frequency of use, approximate date of last use.

6 37. Does applicant have any current or past history of substance abuse treatment? Yes No a. If yes, please list name, address and phone number of all substance abuse providers. 38. Is applicant involved in any 12-step or other self help recovery programs? Yes No a. If yes, which program(s)? 39. If applicant is substance free, for how long has s/he been substance free? 40. If applicant is currently using substances, is s/he interested in substance abuse treatment? Yes No a. If no, what type of treatment is applicant interested in? 41. Does applicant have a history of any medical conditions? Yes No a. If yes, please list conditions. If applicable, please list hospitalizations for these medical conditions. 41a. Date of last physical; OB/GYN, and dental appointments for all household members as appropriate: 42. Is applicant allergic to any medications? Yes No a. If yes, please list medication allergies. 42A. PLEASE LIST CURRENT MEDICATIONS THE TENANT IS ON: 43. Where does applicant receive medical care? Please list name, address and phone number of all health care providers.

7 SOCIALIZATION 44. Describe applicant s participation in faith/spiritual activities, if any? 45. Describe applicant participate in any social networks, or recreational activities? Please list the name(s) of the social/recreational network: VOCATIONAL & EDUCATION HISTORY 46. Does applicant or anyone living with him/her have a source of income? Yes No a. What is the source of income? 47. Does applicant or anyone living with him/her have any entitlements pending? Yes No a. What entitlement(s) is/are pending? Person Receiving Other s Date Applied Amount Income Name Source of Income Receiving Applicant Other a. Social Security Income (SSI) $ Applicant Other b. Social Security Disability Income (SSDI) $ Applicant Other d. General Assistance (SAGA) $ Applicant Other e. Temporary Aid to Needy Families (TANF) $ Applicant Other f. Child Support $ Applicant Other n. Alimony $ Applicant Other g. Veteran Benefits $ Applicant Other h. Employment Income $ Applicant Other i. Unemployment $ Applicant Other j. Medicare $ Applicant Other k. Medicaid $ Applicant Other l. Food Stamps $ Applicant Other m. Other (please specify) $ Applicant Other n. No financial resources $ 48. Please list any outstanding debts, including type of debt and amount: 49. Please list any financial obligations including the amount (e.g. child support, alimony): 50. Is applicant currently employed, either part-time or full-time? Yes No a. If yes, where is applicant employed? b. If no, does applicant wish to be employed, either now or in the future? Yes No b2. If yes, in what area of employment does applicant wish to work?

8 c. Describe applicant s work experience or history, if applicable. 51. Does applicant need training or vocational support to achieve employment in desired occupation? Yes No 52. Is applicant currently participating in vocational or employment training programs? Yes No a. If yes, please identify the training program? b. If no, does applicant wish to enroll in a vocational or employment training program? Yes No 52a. Is applicant currently enrolled in an educational program, either part-time or full-time? Yes No a. If yes, where is the applicant enrolled? b. If no, does the applicant wish to be enrolled, either now or in the future? Yes No LEGAL INFORMATION/HISTORY 53. Does applicant have any current legal issues? Yes No a. If yes, please list description of charges and any pending court dates. b. Does applicant have legal representation? Yes No b2. If yes, please list name and address and phone number of attorney or legal advocate. 54. Is applicant currently on probation? Yes No 55. Is applicant currently on parole? Yes No a. If yes to either #54 or #55, please list name and contact information of probation/parole officers(s) 56. Does applicant have any prior arrests, convictions or incarceration? Yes No a. If yes, please list.

9 57. Does applicant have a conservator? Yes No a. If yes, is he/she a conservator of person? Yes No, b. If yes, is he/she conservator of estate (money)? Yes No c. If yes, is he/she conservator of both person and state? Yes No d. If yes, enter name and address of conservator: ADL s 58. Does the applicant have difficulty with any of the following areas of daily living? In addition, please list any strengths the tenant may have. Check all that apply. a. Paying rent/utilities b. Lease compliance c. Housekeeping d. Money management e. Driving/using public transportation f. Arranging apartment repairs g. Use of mental health services h. Use of health services i. Securing/Maintaining Benefits j. Meal preparation k. Shopping for food and other necessities l. Taking medication as prescribed or instructed m. Filling prescriptions n. Socialization o. Hygiene p. Other (specify):

10 EMERGENCY CONTACT 59. Emergency Contact: Telephone # Address: Date of Application for Housing: Applicant: Date Signature Case Manager: Date Signature Case Management Supervisor: Signature Date

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